Posttraumatic stress disorder (PTSD) is a chronic and debilitating mental condition that develops in response to catastrophic life events, such as military combat, sexual assault, and natural disasters. The symptoms of PTSD are divided into 3 symptom clusters: reexperiencing, avoidance, and hyperarousal. In addition, trauma survivors often experience guilt, dissociation, alterations in personality, difficulty with affect regulation, and marked impairment in ability for intimacy and attachment.1,2 Disorders comorbid with PTSD include depression, substance abuse, other anxiety disorders, and a range of physical complaints.3,4
Over the past several decades, considerable progress has been made in the development and empirical evaluation of assessment instruments for measuring trauma exposure and PTSD as well as related syndromes, such as acute stress disorder. The measures that have been developed, including questionnaires, structured interviews, and psychophysiological procedures, have been extensively validated and many have been widely adopted internationally. PTSD assessments were developed to be psychometrically sound; to collect information from multiple sources across response channels; and to use across different trauma populations, settings, genders, ethnic groups, and cultures.5-8
This article, based on a comprehensive review by Weathers and associates,9 provides a selective and brief summary of trauma and PTSD assessments in adults.
The current diagnostic criteria for PTSD include10:
• Exposure to a traumatic stressor (criterion A)
• The development of a characteristic syndrome involving reexperiencing, avoidance and numbing, and hyperarousal symptoms (criteria B through D)
• Duration of at least 1 month (criterion E)
• Clinically significant distress or impairment in social or occupational functioning (criterion F).
A comprehensive assessment of PTSD evaluates all of the diagnostic criteria, assesses associated features and comorbid disorders, and establishes a differential diagnosis. Although some of these tasks can be accomplished with self-report measures, most are best accomplished with a structured interview. Clinical interviews provide opportunities to ask follow-up questions, to clarify items and responses, and to use clinical judgment in making the final ratings.
It is necessary to establish that an individual has been exposed to an extreme stressor that satisfies the DSM-IV definition of trauma as described in criterion A. The patient must have directly experienced the event, witnessed it, or learned about it indirectly; the event must have been life-threatening, involved serious injury, or threatened physical integrity; and it must have triggered an intense emotional response of fear, horror, or helplessness.
In addition to identifying an index event for symptom inquiry, it is important to assess for exposure to other traumatic events across the life span. Exposure to multiple lifetime traumas is typical, and previous traumas may influence reactions to the index event.3,11 The target trauma is identified as the one that is currently causing the most frequent and severe symptoms. The 17 PTSD symptoms are then rated in relation to that event (Table 1). In addition to evaluating the diagnosis and severity of PTSD, a comprehensive assessment often includes an evaluation for the presence of comorbid disorders and associated features.
Several measures are available to help diagnose PTSD and assess its severity. These include structured interviews, self-report measures, and multiscale personality inventories (Table 2).
? Posttraumatic stress disorder (PTSD) assessment instruments are psychometrically sound, can be used to collect information from multiple sources, and can be used to measure different trauma populations.
? Although structured interviews, self-report measures, and multiscale personality inventories are available for assessing PTSD, a structured interview is recommended to evaluate all of the diagnostic criteria, assess associated features and comorbid disorders, and establish a differential diagnosis.
? In addition to identifying an index event for symptom inquiry, it is important to assess patients for exposure to other traumatic events across their life span.
The comprehensive Structured Clinical Interview for DSM-IV (SCID) is designed to help diagnose all the major DSM-IV disorders.12 As with all SCID modules, the PTSD module maps directly onto DSM-IV diagnostic criteria. The SCID PTSD module appears to have good reliability and convergent validity in a variety of samples and settings.13-15
The Clinician-Administered PTSD Scale (CAPS), which was developed in 1989 at the National Center for PTSD, is a comprehensive structured interview for PTSD.16,17 The CAPS consists of 30 items: 17 items assess DSM-IV symptoms of PTSD; 5 assess onset, duration, subjective distress, and functional impairment; 3 assess overall response validity, symptom severity, and symptom improvement; and 5 assess associated symptoms, including trauma-related guilt and dissociation. In addition, the CAPS assesses criterion A by means of the Life Events Checklist, which screens for possible trauma exposure. It also includes a trauma inquiry section that evaluates criterion A and identifies an index event for symptom inquiry. At the symptom level, the CAPS yields continuous and dichotomous scores for each item, and at the syndrome level it yields a continuous measure of overall PTSD symptom severity in addition to a dichotomous PTSD diagnosis.
1. Herman JL. Trauma and Recovery. New York: Basic Books; 1992.
2. Wilson JP. PTSD and complex PTSD: symptoms, syndromes, and diagnoses. In: Wilson JP, Keane TM, eds. Assessing Psychological Trauma and PTSD. 2nd ed. New York: The Guilford Press; 2004:7-44.
3. Kessler RC, Sonnega A, Bromet E, et al. Posttraumatic stress disorder in the National Comorbidity Survey. Arch Gen Psychiatry. 1995;52:1048-1060.
4. Schnurr PP, Green BL, Kaltman SI. Trauma exposure and physical health. In: Friedman MJ, Keane TM, Resick PA, eds. Handbook of PTSD: Science and Practice. New York: The Guilford Press; 2007:406-424.
5. Keane TM, Wolfe J, Taylor KL. Post-traumatic stress disorder: evidence for diagnostic validity and methods of psychological assessment. J Clin Psychol. 1987;43:32-43.
6. Kulka RA, Schlenger WE, Fairbank JA, et al. Assessment of posttraumatic stress disorder in the community: prospects and pitfalls from recent studies of Vietnam veterans. Psychol Assess. 1991;3:547-560.
7. Marsella AJ, Friedman MJ, Gerrity ET, Schurfield RM, eds. Ethnocultural Aspects of Posttraumatic Stress Disorder: Issues, Research, and Clinical Applications. Washington, DC: American Psychological Association; 1996.
8. Kimerling R, Ouimette PC, Wolfe J, eds. Gender and PTSD. New York: The Guilford Press; 2002.
9. Weathers FW, Keane TM, Foa EB. Assessment and diagnosis of posttraumatic stress disorder. In: Foa EB, Keane TM, Friedman MJ, Cohen JA, eds. Effective Treatment for PTSD. New York: The Guilford Press; 2008.
10. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: American Psychiatric Association; 1994.
11. Breslau N, Kessler RC, Chilcoat HD, et al. Trauma and posttraumatic stress disorder in the community: the 1996 Detroit Area Survey of Trauma. Arch Gen Psychiatry. 1998;55:626-632.
12. First MB, Spitzer RL, Gibbons M, Williams JB. Structured Clinical Interview for DSM-IV Axis I Disorders, Clinical Version (SCID-CV). Washington, DC: American Psychiatric Press; 1996.
13. Keane TM, Kolb LC, Kaloupek DG, et al. Utility of psychophysiological measurement in the diagnosis of posttraumatic stress disorder: results from a Department of Veterans Affairs Cooperative Study. J Consult Clin Psychol. 1998;66:914-923.
14. Zanarini MC, Skodol AE, Bender D, et al. The Collaborative Longitudinal Personality Disorders Study: reliability of axis I and II diagnoses. J Personal Disord. 2000;14:291-299.
15. Zanarini MC, Frankenburg FR. Attainment and maintenance of reliability of axis I and II disorders over the course of a longitudinal study. Compr Psychiatry. 2001;42:369-374.
16. Blake DD, Weathers FW, Nagy LM, et al. A clinician rating scale for assessing current and lifetime PTSD: the CAPS-1. Behav Ther. 1990;13:187-188.
17. Blake DD, Weathers FW, Nagy LM, et al. The development of a Clinician-Administered PTSD Scale. J Trauma Stress. 1995;8:75-90.
18. Foa EB, Riggs DS, Dancu CV, Rothbaum BO. Reliability and validity of a brief instrument for assess-ing post-traumatic stress disorder. J Trauma Stress. 1993;6:459-473.
19. Foa EB, Tolin DF. Comparison of the PTSD Symptom Scale–Interview Version and the Clinician-Administered PTSD Scale. J Trauma Stress. 2000;13:181-191.
20. Davidson JR, Smith RD, Kudler HS. Validity and reliability of the DSM-III criteria for posttraumatic stress disorder: experience with a structured interview. J Nerv Ment Dis. 1989;177:336-341.
21. Davidson JR, Malik MA, Travers J. Structured interview for PTSD (SIP): psychometric validation for DSM-IV criteria. Depress Anxiety. 1997;5:127-129.
22. Foa EB. Posttraumatic Stress Diagnostic Scale [Manual]. Minneapolis: National Computer Systems; 1995.
23. Foa EB, Cashman L, Jaycox LH, Perry KJ. The validation of a self-report measure of posttraumatic stress disorder: the Posttraumatic Diagnostic Scale. Psychol Assess. 1997;9:445-451.
24. Weathers FW, Litz BT, Herman DS, et al. The PTSD Checklist (PCL): reliability, validity, and diagnostic utility. Paper presented at: the Annual Meeting of the International Society for Traumatic Stress Studies; 1993; San Antonio, TX.
25. Blanchard EB, Jones-Alexander J, Buckley TC, Forneris CA. Psychometric properties of the PTSD Checklist (PCL). Behav Res Ther. 1996;34:669-673.
26. Ruggiero KJ, Del Ben K, Scotti JR, Rabalais AE. Psychometric properties of the PTSD Checklist—Civilian Version. J Trauma Stress. 2003;16:495-502.
27. Davidson JR. Davidson Trauma Scale. Toronto: Multi-Health Systems; 1996.
28. Davidson JR, Tharwani HM, Connor KM. Davidson Trauma Scale (DTS): normative scores in the general population and effect sizes in placebo-controlled SSRI trials. Depress Anxiety. 2002;15:75-78.
29. Horowitz MJ, Wilner NR, Alvarez W. Impact of Event Scale: a measure of subjective stress. Psychosom Med. 1979;41:209-218.
30. Weiss DS, Marmar CR. The Impact of Event Scale–Revised. In: Wilson JP, Keane TM, eds. Assessing Psychological Trauma and PTSD. New York: The Guilford Press; 1997:399-411.
31. Weiss DS. The Impact of Event Scale–Revised. In: Wilson JP, Keane TM, eds. Assessing Psychological Trauma and PTSD. 2nd ed. New York: The Guilford Press; 2004:168-189.
32. Keane TM, Caddell JM, Taylor KL. Mississippi Scale for Combat-Related Posttraumatic Stress Disorder: three studies in reliability and validity. J Consult Clin Psychol. 1988;56:85-90.
33. King LA, King DW. Latent structure of the Mississippi Scale for Combat-Related Posttraumatic Stress Disorder: exploratory and higher-order confirmatory factor analyses. Assessment. 1994;1:275-291.
34. King DW, King LA, Fairbank JA, et al. Enhancing the precision of the Mississippi Scale for Combat-Related Posttraumatic Stress Disorder: an application of item response theory. Psychol Assess. 1993;5:457-471.
35. McFall ME, Smith DE, Mackay PW, Tarver DJ. Reliability and validity of the Mississippi Scale for Combat-Related Posttraumatic Stress Disorder. Psychol Assess. 1990;2:114-121.
36. Hathaway SR, McKinley JC. Minnesota Multiphasic Personality Inventory: Manual for Administration and Scoring. New York: Psychological Corporation; 1951.
37. Butcher JN, Graham JR, Ben-Porath YS, et al. Minnesota Multiphasic Personality Inventory–2: Manual for Administration, Scoring, and Interpretation. Rev ed. Minneapolis: University of Minnesota Press; 2001.
38. Penk WE, Rierdan J, Losardo M, Robinowitz R. The MMPI-2 and assessment of posttraumatic stress disorder (PTSD). In: Butcher JN, ed. MMPI-2: A Practitioner’s Guide. Washington, DC: American Psychological Association; 2006.
39. Morey LC. Personality Assessment Inventory Professional Manual. 2nd ed. Odessa, FL: Psychological Assessment Resources; 2007.